Provider Demographics
NPI:1225108657
Name:FREDSTROM, O'ANN KARIN (MD)
Entity Type:Individual
Prefix:DR
First Name:O'ANN
Middle Name:KARIN
Last Name:FREDSTROM
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:P O BOX 15540
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:WY
Mailing Address - Zip Code:83002
Mailing Address - Country:US
Mailing Address - Phone:307-734-8800
Mailing Address - Fax:307-734-8900
Practice Address - Street 1:610 WEST BROADWAY
Practice Address - Street 2:SUITE L02
Practice Address - City:JACKSON
Practice Address - State:WY
Practice Address - Zip Code:83001
Practice Address - Country:US
Practice Address - Phone:307-734-8800
Practice Address - Fax:307-734-8900
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-09
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WY5032A174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WY113880400Medicaid
W303497Medicare ID - Type Unspecified
WY113880400Medicaid